Please print clearly. Your reimbursement will depend on this form being filled out properly.
Name Social Security #________________________
City / State / Zip Phone #
Stipend Applying for: (Can only apply for one stipend.)
--------Gifted and Talented. A stipend of $200.00 is available for the first 15 registrants. To be
eligible for the stipend an individual must attend the Gifted and Talented-Level II training provided
at the Summer Institute (June 8 and 9).
_____Counseling. A stipend of $200.00 is available for the first 10 registrants. To be eligible for
the stipend an individual must attend the Transforming School Counseling in Montana-Level I
training provided at the Summer Institute on June 6.
Important Information: You will be notified by email if approved for the stipend. The stipend will
be paid after the conclusion of the Summer Institute and the completion and processing of the
necessary paperwork by the university. A signed W9 Form must be completed for the stipend to be
Participant Signature Date
Send Completed form to: John Keener, MCD, 1500 University Drive, Billings, MT 59101, or fax to
406-657-2313, or email to email@example.com. Thank you.
For MCD use only
Index # ____________
MCD Authorized Signature Date